Get Well Soon

In part I, we discussed the impact of Type II Diabetes on our health and the extent of the epidemic of diabetes in Canada and the world:

9% of Canadians are diabetic, up from 3.3% in 1998

almost 30% of Canadians live with diabetes or pre-diabetes

in the UK – the NHS spends 10% of the health budget on diabetes

1/10 Canadian deaths are attributable to diabetes

conventional treatment does not prevent or reverse diabetes, as it focuses on glycemic control to attempt to prevent complications from diabetes

The traditional approach can be summarized as:

eat less

avoid fat

exercise more

prescribe early

intensify medications to maintain glycemic control

prescribe other medications to control for other risk factors

hypertension

high cholesterol

Following this conventional approach, the probability of a diabetic achieving remission (normal blood sugars without medication) is very low. In a large cohort study of 122,781 patients in the Kaiser Permanente health system, the 7-year cumulative incidence of achieving any remission was 1.6% overall and 4.6% in a sub-group of newly diagnosed (< 2 years) diabetics.(1)

Yet we have clear evidence that diabetes can be reversed.

The first hint of this reversal comes from the outcomes of bariatric surgery. In 1992, Pories et al. showed that blood glucose levels normalized in obese people with Type 2 diabetes who had undergone bariatric surgery and that almost 10 years later 90% remained free of diabetes.

The effect of bariatric surgery to reverse diabetes has been replicated in numerous studies with rates of remission ranging from 30 to 70% depending on the procedure and trial.

Overall the long term remission correlates with the amount of fat loss achieved and maintained.

But this correlation may be misleading when it comes to causation.

The changes in insulin resistance and blood sugar happen well before there is any significant loss of fat. Initially there was belief that these early effects were mediated through incretin hormone secretion.

Closer analysis shows that real change happens through the initial rapid decline in caloric intake at the time of surgery. This creates a sudden reversal of traffic into fat stores that brings about a profound change in the intracellular concentration of fat metabolites. This effect happens first in the liver and other ectopic (visceral) fat storage sites.

These changes represent a sudden and dramatic reversal of the proposed cause of insulin resistance.

With this evidence that Type II DM can be reversed by bariatric surgery and that the effect results from the immediate reversal of the intracellular changes that cause insulin resistance and diabetes in the first place, the next question is can this be done through diet - without the cost, risk and complications of surgery. The simple and resounding answer is YES:

Type II DM can be reversed through dietary interventions.

Before we look at the therapeutic nutrition trials that are now providing evidence that diabetes is reversible, I want to step back and look at the mechanism and time course of insulin resistance, as this will help us understand what approach an individual looking to reverse diabetes should follow.

Insulin resistance is a process by which muscle, fat and liver cells no longer respond properly to insulin and thus cannot easily absorb glucose from the bloodstream. As a result, the body needs higher levels of insulin to help glucose enter cells.

The liver is the key player in the development of diabetes, as it is the hepatic production of triglycerides from excess carbohydrates that is at the root of the disease process.

Interestingly, it is the reversal of insulin resistance in the liver that occurs during the immediate hypocaloric response to bariatric surgery.

The trigger theory for the twin cycle explains the mechanism for both the development and reversal of Type II DM, and provides the foundations of a strategy for a new paradigm for diabetes management.

The key is to understand at what the point the trigger is activated in the liver, that is the point at which liver fat accumulates along with the corresponding trigger level at which adverse metabolic effects of fat on the pancreas occur. The goal of any therapeutic effort to reverse diabetes would then be to reduce the liver and pancreas fat below the personal trigger levels.

The key here is the liver: we have known for some time that insulin resistance in Type II DM correlates with liver fat - decrease the liver fat and the diabetes improves.

How do we decrease liver fat?

improve insulin sensitivity in muscle

stop the consumption of fructose

stop the consumption of alcohol

reduce the level of caloric intake to reverse the flow of fat from the liver

It is this last point that illustrates why the reversal of diabetes in bariatric surgery comes with the dramatic and immediate induction of a hypocaloric diet.

If bariatric surgery’s immediate effect on diabetes results from this hypocaloric induction – can this be done through diet alone, without surgery.

In Part III, we will explore some of the new and powerful evidence for therapeutic nutrition that demonstrates that Type II Diabetes is in fact reversible through dietary interventions.

In medical school we were taught that Type II DM is a chronic progressive disease - once diagnosed, it could potentially be managed, controlled, but never cured.

The primary thrust of diabetic cares has been to try and control blood sugar with a goal of decreasing the risk of macrovascular (heart attack and stroke) and microvascular (kidney failure and blindness).

Conventional wisdom has been that 90% of diabetics require medication treatments that need to intensified over time to effectively prevent complication and that "delays in intensification of are common and may be due to unrealistic patient expectations." (1)

Evidence is accumulating that conventional wisdom has been wrong.

The Massive Toll of Diabetes

Diabetes rates globally are rising, driven by the obesity epidemic. ​In Canada, 9% of the population is diabetic - this has grown from 3.3% in 1998 and is expected to grow to 12% in 2025.

Perhaps even more alarming, an additional 22% of the population are pre-diabetic, 90% of whom do not realize it. Over 70% of pre-diabetics will go on to develop diabetes.

Diabetes reduces lifespan by 5-15 years and accounts for over 10% of deaths in Canadian adults.

People with diabetes are:

over three 3 times more likely to be hospitalized with cardiovascular disease

12 times more likely to be hospitalized with end-stage renal disease and

over 20 times more likely to be hospitalized for a non-traumatic lower limb amputation compared to the general population.

Diabetics have a 25% greater chance of developing cancer. Diabetes is moderately associated with cancers of the:

Diabetes and depression create a self-enforcing viscous cycle: 30% of diabetics have clinically relevant depressive symptoms, people with depression have a 60% increased risk of developing type 2 diabetes.

Adding to this massive clinical toll, the cost of diabetic care is staggering - in Canada we currently spend $15B on treatment and management of complications. With the rates of diabetes climbing the cost trend has been called an economic tsunami, with an expected doubling by 2025.

Looked at from both the clinical and financial perspective, it is clear that diabetes is the biggest healthcare challenge of our generation.

Stepping back, we can see that our traditional approach:

eat less

avoid fat

exercise more

prescribe early

intensify medications to maintain glycemic control

prescribe other medications to control for other risk factors

hypertension

high cholesterol

... is not working, for the simple reason: our current approach does not address the cause of diabetes.

The chronic and progressive nature of diabetes may have more to do with our management than of the disease itself.

In part II and III of this blog series, I will look at the powerful new evidence that Type II Diabetes can be reversed through a comprehensive lifestyle approach.

At Wellness Garage, we believe that the answer to optimal health and vital longevity lies in our lifestyle behaviors. We use comprehensive, evidence-based, precision health assessments to gain deep understanding of an individuals current health and behaviors. We then use this information to come up with a behavioral plan to address underlying illness and risk, while optimizing health.

In the coming months, Wellness Garage will be launching a comprehensive diabetes program aimed at disease reversal and remission based on evidence from powerful new studies. Part II and Part III of this blog series will explore this evidence and detail the Wellness Garage approach.